Post-independent governments in east and Southern African (ESA) countries have all recognised that social participation is central to the success of primary health care (PHC) oriented health systems. There are, however, wide differences in how far they are implementing this policy view. The 2012 EQUINET Equity Watch report found many shortfalls in meaningful levels of social participation in health systems. Health Centre Committees (HCCs) are known by a range of names in different countries but are joint community- health worker structures at primary care level. They offer one way for systems to facilitate social participation and shared decision making between communities and health personnel. There is evidence that they can contribute to quality of and equity in access to health care and improved health outcomes. At a recent EQUINET regional meeting delegates identified ways to better tap into and support this valuable resource for health.
Building on prior work in EQUINET, twenty delegates from seven ESA countries and three international organisations, all working with HCCs, gathered at a regional meeting in February 2014 hosted by Training and Research Support Centre in association with Community Working Group on Health and Medico International in February 2014 to exchange experience on and learning from work to train and strengthen the role of HCCs (The report of the meeting and background paper are available at www.equinetafrica.org).
Dr Portia Manangazira from Zimbabwe’s Ministry of Health and Child Care opening the meeting concurred that HCCs provide a key mechanism for communities to participate in revitalising PHC and for strengthening and monitoring service delivery.
Despite this, while HCCs exist in some form in most countries, they often have no formal legal status or are not trained, resourced or active. In Zambia, the 1995 National Health Services Act provided in law for the District Health Boards and Neighbourhood Health Committees (NHCs). When this was repealed in 2006, it removed the legal mandate for HCCs. Yet in Zimbabwe it has been raised that expecting HCCs to manage public funds from government or external funders without a clear legal mandate is a problem. Even where government guidelines provide for HCCs, they vary in detail. For Zambia, an NHC working group has prepared explicit operational guidelines on establishment, composition, functions and monitoring mechanisms for NHCs. In South Africa, on the other hand, the provisions are more vague and left for the provincial authorities to decide. Generally while guidelines often set HCC composition and duties, they are less clear on how they are funded or on their role in towards social accountability. Despite their role in bringing community voice to service planning and the requirement that they represent communities, HCC members are not always elected by communities, have variable levels of community involvement and influence and may be liable to political control.
To some extent this reflects ambivalence towards whether HCCs are more a voice for the community to influence health services, or an outreach for services to reach and influence communities. Both roles are important, but where do HCCs focus their time and energies? In the Western Cape, South Africa for example, a baseline assessment in two districts found that HCC members spent limited time engaging the community and were spending more time as service volunteers - in security or as queue monitors for example. Similar concerns existed in Uganda. There was concern that in some countries HCC roles have become ‘commodified,’ with the resources available to them based less on community interests or needs than on what is paid for, often by international organisations.
Hence rather than the common practice of a long list of apparently delinked and equally weighted roles, the meeting identified roles of an HCC in a more systemic way, linking these to processes in health systems. The process starts with building an informed health literate community, obtaining community views and drawing on this to bring community voice and experience into the interaction with health service personnel, to jointly design and implement plans and budgets for the health system at primary care and community level. This joint role in governance gives the HCC the information, authority and motivation to go back to communities to facilitate dialogue and social action on health plans; to make sure that the agreed plans have been implemented, and that the duty bearers are capacitated, supported and resourced to deliver on plans and that they do so in a manner that is responsive to the community. HCC members should thus bring the direct experience and views of communities into the system, supporting understanding and reflection within communities on how to improve health, and advocating for improvements, with other sectors or at higher levels of the health system. This means that HCCs are more likely to thrive where health systems are themselves PHC oriented, facilitate action on the social determinants of health and support participatory planning and practice, than where they are organised largely around individual medical care with top down power.
HCC members need to have resources and skills across all these areas of functioning to complement their inherent social capacities and to enable them to overcome power imbalances in the relationships between themselves and health authorities. While there is a lot of training activity taking place, this may be limited to specific disease problems or interventions, may not address the general community health literacy or spectrum of HCC abilities needed and may lack follow up to evaluate its effectiveness or to sustain it. Training may not include some key areas such as budget tracking or assessment of community benefit. Further those providing training for HCCs may themselves lack competencies to build skills in areas such as budget planning or tracking.
Delegates also recognised that for HCCs to be effective in PHC oriented roles, communities themselves need to be health literate and empowered. Social rights to health care, to information and meaningful participation can provide a foundation for this and should be included in all constitutions of the region and in updated national or public health law. Regulations should more clearly define the duties, powers, roles and constitution of HCCs, and guidelines set these in a more systematic manner. However all this is likely to remain on paper unless it is accompanied by processes for capacitating systems and for supporting social activism and information.
The meeting thus proposed a number of areas for follow up attention and action by national authorities and organisations working in health, in relation to legal provisions, guidance, election, composition, functioning and capacity building of HCCs. While the specific cultural contexts differ, it was proposed that the ESA region set minimum guidance for these areas, such as on the core content of and processes for comprehensive HCC training, and that countries budget for the capacity building and functioning of HCCs. As for all other areas of health system performance, it was proposed that the health information system and communities monitor and collect information on the functioning, performance and impact of HCCs. Selected indicators were proposed for this, for further dialogue and development.
The organisations attending the meeting made a commitment as a network of practitioners working with HCCs to continue to link regionally, including to document, to share and make their work more visible. At a time of increasing attention to domestic resources for health, delegates drew attention to the most critical resources in the region- the people. The challenge was raised for policy actors in the region to turn commitments into action and to give systematic attention to the effective functioning of HCCs, as key social assets for health.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org. The report of the Regional meeting referred to can be found at
http://www.equinetafrica.org/bibl/docs/EQ%20HCC%20Mtg%20Rep%20FEB2014.pdf
Editorial
The World Health Organization (WHO) states in its constitution that it aims to achieve "the attainment by all people of the highest possible level of health.” The World Health Assemblies (WHAs) provide a key opportunity to engage on the achievement of this aim. Yet in an interesting study by Kitamura et al. in May 2013 in Health Policy reviewing the agendas of the WHAs between 1970 and 2012, the authors concluded that “agenda items of the WHA do not always reflect international health issues in terms of burdens of mortality and illness.”
So how are countries and stakeholders shaping the WHA agenda?
One way is through the WHO Executive Board (EB), particularly as it plays a role in setting the provisional agenda for the WHA. EB members are individuals nominated by countries with technical expertise in health. Of the 34 members of the Executive Board, seven are from the African region. Currently these are from Cameroon (2011-2014), Chad (2012-2015), Namibia (2013-2016), Nigeria (2011-2014), Senegal (2011-2014), Sierra Leone (2011-2014) and South Africa (2013-2016). As EB members, they are well-positioned to be heard and to bring concerns from their regions to the table. They can also block issues being discussed. The WHO secretariat also plays a role in agenda setting. Procedurally, the provisional EB agenda is proposed by the WHO Director-General. Getting issues on the agenda for the WHA is, however, not difficult. According to the rules of procedure, every proposal brought by a member state and any proposals submitted by the DG should be included in the provisional WHA agenda. So how are these policy levers being used?
Take the 2014 EB agenda for example. Many agenda items were not controversial as they are carried over from previous years, after broad agreement around their importance. This included non-communicable diseases (NCDs), neglected tropical diseases and reform of the WHO. Other agenda items may be more controversial. For example, when in 2012 the United States of America and Thailand successfully petitioned to include lesbian, gay, bisexual and transgender (LGBT) access to health in the WHO EB agenda for consideration it provoked debate, with Egypt and Nigeria, on behalf of their regions, asking for the item to be deleted.
This issue exemplified how health concerns can reflect and raise political division. Bringing health into diplomacy platforms, including that of the WHO, poses a challenge for how to avoid foreign policy concerns overshadowing health issues. The US delegate, Nils Daulaire, speaking about the demands for deletion of the LGBT item in 2012 said that it was “unprecedented for WHO member states to come together to attempt to remove an item legitimately placed on the Executive Board agenda by another member state. We believe it is important to afford each other the courtesy to discuss these important health items, even those with which not everyone agrees. Changing this deeply-established precedent risks politicizing all EB agenda items moving forward.” At the same time, countries are sensitive about health platforms being used to advance wider foreign policy agendas.
On the specific agenda item, a compromise position was reached to delete it and to ask the DG to consult with members on how to address the public health issues for future discussion. African diplomats in Geneva noted that the issue could continue to cause a stalemate unless the DG brings compromise solutions from her consultations within the regions. In the 2014 EB the item thus appeared as ‘[deleted]’ on the final agenda, and there was no discussion of it, as Member States had not agreed on a title or content of accompanying documentation for it. Until they do, the item will not be discussed.
Agenda setting can and does thus fall victim to politics and requires diplomacy to reach solutions that are acceptable to the membership. However African countries have successfully brought items to the WHA agenda, such as that of ethical recruitment of health workers. What may restrict both the inclusion and action on agenda item may be the limits set by the General Program of Work (GPW). The GPW is set for the organization every 5 years. Unless a suggested item falls within the GPW and has funding allocated to it, it is unlikely to make it onto the formal agenda. The Organization is currently working on its 2014-2019 GPW and bases its’ plans on a set of distinct categories in the GPW that have been agreed to by Member States - that is communicable diseases, non-communicable diseases, promoting health through the life course, health systems, and preparedness, surveillance and response. One reform of the WHO underway, according to the WHO website, is to “allow greater flexibility in allocating resources to priorities within these categories”, which may then give flexibility for new agenda items not yet covered in the GPW.
Even when issues make it to the WHA agenda, will they receive adequate attention?
The agenda of both the EB and the WHA have become longer and longer over the years. In May 2013, for example, the WHA agenda included numerous weighty issues, including health post 2015, NCDs, communicable diseases (including malaria and neglected tropical diseases), WHO reform, substandard/spurious/falsely-labelled/falsified/counterfeit medical products and a range of other issues. With such packed agendas, smaller delegations to the WHA face challenges in participating when equally important issues are being discussed at the same time. Dr. Emmanuel Makasa, health attache at the Zambia high commission in Geneva noted in one 2013 meeting in the region that African delegations have responded to this by working as a group: “We work together as the African Group of Health Experts in Geneva to tackle issues and engage as a group, which helps with our individual member state staff shortages and different professionals present at the meetings.”
A lengthening agenda may also reflect the widening reach of global factors and policies in health, or the widening range of concerns claiming for attention. Either way, countries need proactive strategies to get their health concerns onto the global agenda, to ensure that they obtain attention and are addressed. It implies long term thinking, preparing and collaborating with partners in advance to develop positions and organizing the evidence, expertise and alliances to raise and advance agenda items. As Chigas et al. highlighted in 2007 those who can early on “frame the definition of the problem and the terms of the collective debate, can have enormous influence on the subsequent negotiations and their outcomes.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The Centre for Trade Policy and Law is working with EQUINET on a research programme on GHD in association with the ECSA HC Strategic Initiative on Global Health Diplomacy. For more information on the issues raised please visit www.equinetafrica.org
According to the United Nation’s 2017 International Migration Report, South Africa is host to an estimated four million migrants. This figure is set against a backdrop of a history of migration into South Africa that was marked by exploitative labour arrangements between South Africa and its neighbouring countries. This history is often treated with a ‘historical amnesia’ of the contribution of migrants to the South African economy and society. Migrants and particularly African migrants are met with a distrust and hostility that appears as xenophobia.
This hostility is also reflected in South Africa’s public health system, which does not adequately incorporate the reality of migration and health, nor address the needs of migrants. The South African Immigration Act is silent on the health rights and needs of migrants, placing them in a vulnerable situation and often leading to their exclusion from the public health system. This situation is worse for undocumented migrants, given their insecure legal status.
In contrast, recent media reports have often focused on ‘how an influx of health migrants’ has placed a strain on the country’s ability to deliver health care to its nationals. Some provincial health departments have lamented the strain on their limited resources due to the demand for services from migrants. These media reports and official pronouncements create conditions for refugees, asylum seekers and undocumented migrants to be denied access to health care services in public hospitals and clinics on the basis of their nationality or legal status. This was described by Crush and Tawonzera in 2011 as a form of ‘medical xenophobia’.
Denying migrants access to health care constitutes a violation of the internationally recognized right to access health care services, a right that is also enshrined in South Africa’s national law. The Bill of Rights in the South African Constitution enshrines equal rights for all persons in the country and affirms values of human dignity, equality and freedom. Migrants are covered by these constitutional rights, including the right to life, to dignity, freedom and security, to access information and to just administrative action. Section 27 of the Constitution guarantees everyone the right to basic health care, affirming that “everyone has the right to have access to health care services, including reproductive health care” and that “no one may be refused emergency medical treatment”.
The violation of migrants’ rights to access health care has grave consequences. For example, in 2015, a migrant woman lost her premature baby, allegedly due to denial of access to health care. In another incident, a migrant woman was forced to give birth at a bus station after allegedly being denied access to two hospitals in Gauteng province. Such denials of care violate rights. They have a gendered, racial and class impact, with poor, black women bearing the brunt of this discrimination.
Beyond the state’s legal obligation to provide access to health care services, there are public health reasons for providing health care services to migrants. The difficult journeys undocumented migrants, asylum seekers and refugees have had to make from their countries to South Africa may have exposed them to health problems, including communicable diseases. Treating these conditions makes public health sense as we live in a shared social space. The health of the local population is linked to that of the migrant population, given their integration into the wider community.
I would therefore argue that the South Africa state should develop a comprehensive multi-sectoral approach to migration and health, beyond infectious diseases and border control. Both the National Health Act and the Immigration Act should explicitly provide for migrant health care. The Immigration Act needs to be amended to adequately reflect the health rights of documented and undocumented migrants. The law should be supported by a comprehensive national policy, that also details how undocumented migrants should be treated, and that is applied universally across all provinces.
We need to advocate for and train health workers to implement migrants’ health rights. Such training, as a collaboration of the South African Department of Health and the Health Professions Council of South Africa, should create and foster an understanding among healthcare professionals of migrants’ health rights and needs. It should also include health administrators, as they are a point of entry for migrants attempting to access health care services.
These measures are necessary as a public health care system that excludes migrants creates conditions for poor public health for all. It increases the vulnerability of migrants, generates and magnifies discrimination and inequalities in health and violates migrants’ constitutional rights to access health care.
This is not just a health and human rights issue. It is also a matter of social justice. Migrant labour, often low wage, has been integral to South Africa’s society and economy, raising the profitability and savings of local business and consumers. It is also a matter of good public health practice. Delivering equitable access to care for migrants can reduce the health and social costs of disease, improve social cohesion, protect public health and human rights and contribute to healthier migrants in healthier local communities.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
When the United Nations General Assembly meets in June to review progress in tackling the AIDS epidemic it will be reminded by civil society globally of the commitment made to ensure universal access to treatment for AIDS by 2010. This commitment has greatest resonance in sub-Saharan Africa where AIDS related mortality is highest. Two years ago, in June 2004 the regional EQUINET conference of civil society, state, academic and parliamentary delegates resolved that the health challenges in east and southern Africa demanded health systems that are universal, comprehensive, equitable, participatory and publicly funded. This also has urgency in a region where poverty is undermining progress in meeting the most basic Millennium Development Goals.
How do these two sets of imperatives relate to each other? Do they reinforce each other or are they competing for policy attention and resources? Does giving urgency to addressing the right to treatment for AIDS boost or weaken efforts to rebuild fragile health systems? This was the focus of debate at a meeting in Cape Town in early May this year that gathered international AIDS activists, people living with HIV and AIDS (PLWHA) and health activists. The meeting was organised by Gay Men’s Health Crisis with support from the Rockefeller Foundation, and focused on “Identifying public policies for scaling up antiretroviral therapy (ART) and strengthening health systems in developing countries”
The gathering of AIDS and health systems activists itself signals a widening social debate on health and health systems, raising the social, economic and political profile of health after decades of market reforms that have undermined equity and solidarity in health and that have weakened public health systems. It builds on new and increased resources that AIDS brings to health systems, and a growth in social movements for health that can strengthen relationships between health services and communities.
Delegates recognised that access to treatment for AIDS is a right, and so too is access to essential health care. An advocacy and public policy agenda that recognises both of these rights of necessity calls for health-systems friendly, people (especially PLWHA) driven approaches to the establishment, scale-up and long-term sustainability of AIDS treatment programs. There has been past debate on whether the speed of responding to treatment rights compromises this goal of building sustainable systems. The AIDS epidemic is an emergency, and the level of avoidable infection and death calls for measures to bring HIV prevention and AIDS treatment services rapidly to community levels. At the same time it is a chronic long term issue that calls for sustainable systems and measures beyond emergency responses.
How can this be achieved? The meeting reinforced the more general call within the region for people centred health systems. The role people play in decision making in the health sector is important, and often weakly recognised. Specific measures were called for to remedy this.
For example it was proposed that decision making structures and processes include the active participation of PLWHAs, their communities, health care workers and other stakeholders from civil society. However, the governance of the health sector is weak in many countries and the acceptance of the role of civil society is contentious for many governments, thus making real participation a challenge in most settings. In order to pave the way for greater involvement, this participation needs to be backed by regulatory frameworks, guidelines, clear policy messages from governments and effective mechanisms and processes to manage this engagement, including for transparently managing conflicts in the interests and priorities of different groups.
Delegates agreed that involvement in decision making and delivery raises a corresponding obligation of PLWHAs and communities to be literate on both HIV prevention and AIDS treatment and on how health systems work. Building on community-based AIDS treatment literacy, health systems literacy is needed to build community knowledge on public health, and the health systems through which prevention and treatment are delivered. Just as AIDS treatment literacy has become a vehicle for mobilising communities around rights of access to ART, so health systems literacy should be a tool to mobilise communities around their collective rights to health and health care.
The desire to move at ‘AIDS speed’ has led to vertical programming to meet short term demands and delegates at the meeting agreed that some verticality is needed in the short term in response to the epidemic. However vertical programmes can only sustain the long term, lifetime delivery of ART if they are integrated within the wider health system. The issue of vertical programming and the integration in health systems is not unique to AIDS, and affects many other disease based programmes. The resources flowing to AIDS programmes gives it specific prominence, however, as the positive and negative systems effects can be pronounced. This issue naturally arose in the dialogue: delegates at the meeting recommended that plans for AIDS treatment programs need to assess which components can be immediately integrated into general health systems and which require vertical implementation in the short- to medium-term. Delegates also raised the need for plans to be set up front for how all vertical components will be integrated into the health system in the medium- and long-term. Whether initial decisions are made to vertically implement certain components of AIDS treatment programmes or to immediately integrate these components into general health systems, delegates raised the need to recognise, monitor and address problems that might arise from whatever approach is adopted. As the meeting noted, this calls for national information systems and research that is able to identify these effects. It also calls for policy processes that are responsive to this information and flexible enough to rapidly correct problems.
EQUINET has raised that fair financing and valuing of health workers is central to rebuilding national health systems in the region. These issues were also central in the dialogue at the meeting.
The absolute shortage of trained health care workers, at crisis levels in some African countries, is now a major impediment to treatment access, and needs short-term action linked to long-term measures. Health systems and AIDS activists agreed on this. Efforts by some governments in east and southern Africa to tackle this issue were noted, and need to be supported, spread, and backed by consultation with health workers. This calls for targets for training and employing health workers, new resources to employ and pay incentives to retain health workers and removal of any international finance institution conditions or fiscal restraints that undermine the application of these measures. The meeting delegates expressed frustration at the slow pace of global discussions and measures to cancel debt, mobilise aid and lift fiscal restraints to support these health system measures, relative to the speed with which these resources are needed.
The meeting agreed that a point of synthesis of all these points is that of support for bottom-up district level planning as this brings communities and health service providers together around priority health needs, including AIDS treatment. A number of key features were raised, for example:
• bottom-up level district planning that involves communities in a substantive way;
• respect for district planning by governments, international agencies, non government organisations and donors;
• ensuring free access to AIDS treatment (and primary health care services) at point of service and addressing other barriers to accessing care, such as transport to health services;
• resource allocation systems that are responsive to district planning.
To this we may add ensuring that health workers at district and primary health care levels are adequate, valued and retained, including ensuring their own access to AIDS treatment, strengthening district level health information and planning systems and revitalising and resourcing the community health worker and primary health care approaches that strengthened the interface between communities and health services.
Finally, the stewardship of global public health, AIDS programs and health systems, needs independent and rigorous external monitoring. The promises made at the 2001 UNGASS were largely promises broken and the new promises made at the 2006 UNGASS in New York need to be held open to greater scrutiny in the years ahead. Stronger mechanisms for monitoring of good practices and stewardship in health at global, regional and country level must be established and led by institutions from developing countries.
The dialogue at the meeting in Cape Town in May provided a useful opportunity to identify shared goals and paths to strengthening health systems and ensuring universal access to AIDS treatment. It now provides a useful ‘watching brief’ for health systems activists and AIDS activists to see how far the dialogue at UNGASS addresses our shared expectations.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org . EQUINET work on equity and health systems strengthening in health sector responses to AIDS is available at the EQUINET website at www.equinetafrica.org . Information on Gay Men’s Health Crisis can be found at http://www.gmhc.org/
The Regional Network for Equity in Health in Southern Africa (EQUINET), Oxfam GB in co-operation with SADC, government, UN, civil society, health sector and international agency partners met in February 2004 to review the options for a sustainable and equitable path to realising the urgent imperative of making antiretroviral therapy (ART) available to southern Africans and the long term imperative of universal treatment access. The organisations identified principles to guide a sustainable and equitable response that would address the urgency of the need to act and the demand to do this in ways that build and do no harm to the already fragile public health systems in southern Africa. There is an opportunity for a virtuous cycle where programmes aimed at delivering ART strengthen health systems and thus widen access to ART. There is also a threat of a vicious cycle of programmes aimed at delivering ART diverting scarce resources from wider health systems and undermining long term access both to ART and to other critical public health interventions. These principles are the basis for the virtuous cycle. They are presented as a discussion document for wider dissemination, discussion and feedback. Feedback is welcomed! Please email your feedback to admin@equinetafrica.org.
1. WHY TREATMENT ACCESS THROUGH SUSTAINABLE PUBLIC HEALTH SYSTEMS?
- Approximately 15 million adults and children in southern Africa are currently infected with HIV and an estimated 700 000 - 1million currently have AIDS. With only one eligible person in 25,000 currently on treatment with antiretroviral therapy (ART), the shortfall is enormous, and widest for the low income communities using peripheral and rural health services. Responding to this scale of disease and shortfall will not be possible through scattered programmes and projects. It requires a comprehensive and co-ordinated approach that embeds treatment within an effective, accessible health system.
- Treatment is only one of the multiple responses to the risk environments and factors that produce HIV and to the many areas of household vulnerability due to AIDS. Household food security, access to primary health care, social security, gender equity and income security are important factors linked to HIV and AIDS in southern Africa. Treatment programmes may excessively shift attention to drugs as the response to AIDS if they do not reinforce the prevention, care and socio-economic programmes that deal with these factors influencing HIV infection and the impacts of AIDS.
- After decades of macroeconomic measures weakening health systems, the capacities lost to public health systems, including the human resources for health, need to be systematically rebuilt to plan, manage and use the significant global and international resources for treatment of AIDS coming into Africa. Treatment activism has opened a real window of opportunity for meeting rights of access to treatment and overcoming unjust barriers to ART. It now needs to join with broader public health activism to ensure that these goals can be realised for all through sustainable, effective and equitable health systems.
- All southern African Development Community (SADC) member states have policies on AIDS and treatment guidelines and some are developing explicit treatment access policies. While legal, clinical and pharmaceutical aspects of these policies are now developed, there is a gap in the health system aspects. This gap needs to be filled if treatment policies are to be implemented in the practical conditions found in southern Africa health systems and to reinforce wider health and social goals.
The current situation does not lend itself to prescription. Southern African countries vary widely in socio-economic status, health system development and in the availability and organisation of resources for health. The choices around how scarce resources are used need to be made in an informed, transparent and participatory manner at the national level. These guiding principles are thus intended to support fair country level processes to develop strategies based on the capabilities, resources and demands of national health systems.
2. PROPOSED GUIDING PRINCIPLES
2.1 Fair, transparent processes to make informed choices.
The choices to be made around use of resources, around the clinical, social and systems criteria for rationing and around opportunity costs and trade-offs call for governments and relevant international and national non-government organisations to provide clear, transparent and accountable mechanisms for public and stakeholder consultation and debate to develop policy and to make policy choices.
2.2 Joint public health and HIV/AIDS planning.
Strategic and operational plans as well as monitoring and evaluation frameworks at national and district levels should be produced through a process that integrates HIV / AIDS planning into broader public health planning. This includes integrating AIDS treatment programmes into HIV/AIDS prevention and social care programmes. Integrated planning should be supported by investments in public health leadership and in the management and monitoring capacities needed to implement plans.
2.3 Integrating treatment into wider health systems.
Governments, international and national agencies should integrate HIV and AIDS prevention, treatment and care programmes into a programme of health systems strengthening and development. Key elements of this programme include:
Strengthening inclusive public health systems:
· Prioritising district and primary level facilities and services as points of entry for ART services over tertiary level services.
· Locating treatment programmes within an effective District Health System, supported by effective district health management structures that provide all basic services for HIV and non-HIV related illness in an integrated and locally appropriate manner.
· Ensuring adequate human resources for treatment programmes integrated within district health systems.
· Co-ordinating and building national networking of information and experience from district sites.
· Services provided by non-profit organisations should be integrated in the public sector framework.
· Private sector provision should complement public provision and not compete for public funding.
2.4 Realistic targets for treatment access with clear guidelines and monitoring systems for ensuring equity in access and quality of care.
The rapid expansion of ART can be achieved through targeting HIV positive current users of the health system, (particularly PMTCT, TB and VCT clients) and certain social and occupational groups (such as those with medical insurance or health workers). Such rapid expansion options should take place with simultaneous and equal investments to build the district health system and PHC infrastructure in areas without the current capacity to sustain effective ART services within clear time frameworks for wider rollout.
2.5 Treatment resources integrated into regular budgets, supported by long term external commitments and through fair financing approaches
Dedicated AIDS funding should be integrated into regular budgets and comprehensive health sector plans. The transfer and use of earmarked funds for AIDS should be transparent. ‘Emergency transfers’ to meet specific system shortfalls should be time-limited with plans for their integration into regular budgets and comprehensive health sector plans.
Additional funds and resources dedicated to HIV/AIDS should be system supporting (covering prevention, treatment, district health system and PHC responses) and include expenditure on broader health care infrastructure where required. This calls for longer term commitments from international agencies (minimum 5 years), in support of joint national HIV/AIDS and health plans, linked to budget and sector wide support with agreed exit strategies. Global and international funds should build predictable, consistent, long term and co-ordinated funding. African governments should increase their health budgets to 15% of total budgets in accordance with the Abuja declaration, and strengthen their governance and management capacities for resource planning and management. Ministries of finance should now integrate health systems demands into financial planning and budget frameworks and review their Medium Term Expenditure Frameworks with the IMF to take account of additional resource inputs demanded for system strengthening.
2.6 Prioritise human resource development in the health sector.
Strategic plans, developed in consultation with health personnel, are required for the health personnel needs and commitments for a health systems approach to treatment access. This should include effective and sustainable in-service and institutional training approaches, provisions for clear career paths, effective human resource management (payroll management, supervision and training), incentives for health workers to work in under-staffed areas and provisions for safe work. Plans for treatment access should not involve deliberate policies of recruitment of staff from other African countries or diversion of scarce personnel from broader health systems into vertical programmes. Any proposed new investment in HIV/AIDS or treatment expansion should include resources and measures for the training, sustaining and retaining of relevant health personnel and for their safe work environments and infection control.
2.7 Strengthen essential drugs policies and systems at national and regional level.
National legislation should now take full advantage of the TRIPS flexibilities and the Doha declaration, particularly provisions for parallel importation and compulsory licensing. Drug regulatory and medicine control authorities should be strengthened, together with drug procurement and distribution systems. The expansion of ART should be included within the essential drugs programmes, through review and update of the essential drugs list. The essential drugs policy should cover the private sector and provide where necessary for mandatory generic substitution (available generic equivalent drug provided when brand name drug prescribed). SADC as a regional body should use TRIPS flexibilities and the Doha commitments to support regional strategies for procurement, price monitoring and negotiation, and quality control of drug supplies. Southern African governments and civil society should promote monitoring, regulation and advocacy within the region and internationally to prevent excessive profiteering and unfair monopolies in the pharmaceutical sector.
3. CONCLUSION
These principles are proposed as central to ensuring that actions to expand access to ART are reinforced, sustained and meet equity policy goals through strengthened health systems. They are proposed:
- for national debate,
- for translation into practical strategies and programmes,
- to gather and share evidence on options for good practice,
- to provide a wider framework for understanding the costs and benefits of approaches to ART access,
- to inform international agency policy and practice and
- to inform advocacy and activism.
They are proposed as a framework for monitoring and evaluating our efforts to expand treatment access. They are as important as targets and are more directly linked to our longer term capacities and aspirations to sustain and expand access to treatment for all those who need it.
When the news came of Nelson Mandela’s death messages came spontaneously on our list from colleagues from across the 16 countries in EQUINET. We can’t include them all but some are below. They signal the pride that Mandela gave to all in being African, the many facets of justice and wisdom he symbolized for people in the continent, his respect for power being located within the people and the inspiration that people drew and will continue to draw from his life. Hamba Kahle Madiba.
From Amuda Baba in Democratic Republic of Congo: It is a big loss for Africa. We have lost a symbol of peace, unity and humility. May his soul rest in peace.
From Severina Lemachokoti in Kenya: His wisdom was unique and his wise words will forever remain to build people of all races in the years to come.
From Moses Lungu in Zambia: We will draw lessons from him on equity, equal and social justice for all. Bless his family and nation
From Sam Wamani in Uganda: Mandela was and will remain a true love for all people of all colours. Africa and the world will always remember Madiba.
From Isabella Matambanadzo in Zimbabwe: He gave us an unmatchable sense of the dignity in being black Africans and of our humanness. ..May we always carry the best of you with us.
From Elisha Sibale in Tanzania: His lifelong commitment to social justice for all was a beacon to the world.
From Dennis Chibuye in Zambia: The world has lost of a true patriot and visionary leader. …Long Live Mandela Spirit.
From: Kingsley Chikaphupha in Malawi: An icon, statesman and a true son of Africa!!
From Wilson Asibu in Malawi: May his life inspire us all, especially the youth who have a great opportunity to sculpture their lives into greatness.
From Jacob Ongala Owiti in Kenya: Mandela had the unique ability to take power to the people - So, who will take up the Mandela's spear and move it forward?
From Fortunate Machingura in Zimbabwe: He said: “To be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others” he said…enhancing the freedom of others implies our joint action as a collective.…it’s now up to us Comrades… the struggle continues!
We wish all a 2014 in which our struggles for health and justice flourish.
*Why is life expectancy in some countries in our region 40 years longer then others?
*How well are we meeting commitments made by leaders to spend 15% of government budgets on health?
*What can we do about the loss of health workers due to migration?
These issues are discussed in the new book published by EQUINET “Reclaiming The Resources For Health: A Regional analysis of equity in health in east and southern Africa” launched in the region in Lilongwe Malawi on October 23rd 2007, at an event locally hosted by REACH Trust Malawi and Malawi Health Equity Network, two EQUINET steering committee member institutions. The book was officially launched by the Principal Secretary for Health, Mr Chris Kang’ombe, with the Chair of the Parliamentary Committee for Health, Honourable Austin Mtukula and speakers from the region, followed by dance and drama presenting health challenges in communities. Hastings Banda from REACH Trust chaired the session, attended by people working in health in Malawi and delegates from seven of the 16 countries in east and southern Africa.
After a welcome by Bertha Simwaka, Acting Executive Director of REACH Trust, and an EQUINET presentation by Rene Loewenson outlining the scope of the book, three speakers from the region explored further the issues raised.
Moses Mulumba, a lawyer with the Law Faculty, Makerere University Uganda outlined how rights to health are often not respected in economic and trade policies. This has led to explicit efforts in Uganda to influence negotiations on trade agreements like the Economic Partnership Agreements, sensitise trade officials, and set human rights guidelines for areas of trade, such as the practices of pharmaceutical companies in relation to access to medicines and to advocate for assessment of the health impact of agreements before signing them.
Bona Chitah from the University of Zambia described Zambia’s attempts to achieve a “dream and up our standards for the good of the people”. Recognising that Zambians have a right to better health, he described the efforts to redistribute health resources, improve access to health services and ensure a holistic, horizontally integrated health system. Recent reviews of cost sharing policies showed how they raised barriers and costs for poor people, leading Zambia to abolish user fees and seek increased financial resources from international sources for health. He pointed to a number of challenges still to address in achieving fair financing for health: “We are awakening to the reality that we are in it for the long haul ... to build the bridge between the current and the dream ...”
Kathne Hofnie-Hoebes from University of Namibia highlighted the necessity of tapping the potential for health action that exists within communities. Drawing on experiences of a marginalised community in an informal settlement in Namibia, she described how using participatory reflection and action approaches builds respect between communities and health workers and builds the confidence of communities to act.
Experiences were also presented from Malawi. Hon Austin Mtuluka, MP and Chair of the Malawi Parliamentary Committee on Health, described the advocacy by parliamentarians for health equity in budget and legal processes. This has yielded gains: Malawi has made progress towards meeting the Abuja target in 2007, with a rise from 8% of the total budget to 14% of the total for 2007/8. Parliamentarians were also involved in drafting a new law on HIV and AIDS, drawing experience from the region. He commented that the exchange of information between parliamentarians across the region has been useful in strengthening parliamentary roles and capacities for tackling health inequity.
Finally the Permanent Secretary for Health from the Ministry of Health Malawi, Mr Chris Kang’ombe officially launched the book. He recognised the significant challenges to achieving global Millennium Development Goals in Africa, and the importance of networking researchers, policy makers, officials and civil society members towards promoting health equity and regional co-operation. He observed, “The perspective that guides the report being launched today is based on shared values of equity and social justice in health and a spirit of self determination.”
He pointed to the book as a relevant source of evidence and analysis, and made links between the themes in the book and the focus areas for development set out in the Malawi Growth and Development Strategy, whose overall theme is ‘From poverty to prosperity. The book draws from regional experience: Strategies applied in Malawi, such as the provision of the essential heaIth package are discussed, together with insights and options for improving equity in access to these services. In his words,
“I would like to encourage and urge each and every one of us working in the health sector and beyond to make sure that we have a copy of this report… Let us participate in implementing the activities and recommendations set out in this report to reduce the health inequalities which currently exist in Malawi and in the east and southern Africa region.”
The tempo after the launch was raised with drumming, singing and dancing marking the entry of the Paradiso Home Based Care dance group. The group’s songs reinforced messages around advancing people’s health, with many joining in dancing. The Tipya Drama Group, a community group in Lilongwe, performed a play about poor communities expectations of their community care, and the need for communities, health workers and planners to have dialogue in addressing these needs. The drama group interpreted messages from the book in their own context, with some local twists!
The launch in Malawi was the regional ‘launchpad’ to disseminating the evidence and experience on health equity from and about the region contained in the book. The health equity challenges in Malawi, as in other countries in the region, are significant. The launch sent clear signals, however, of the affirmative intention, options and social resources to act on these challenges from within the region.
Information on where to obtain a copy of “Reclaiming the resources for Health” can be found on the EQUINET website (www.equinetafrica.org) or send queries to admin@equinetafrica.org.
The World Health Organisation has its first ever director-general from Africa, after the election of Dr Tedros Adhanom Ghebreyesus, the former Ethiopian health minister, who will begin his term in July 2017. In a speech to the World Health Assembly Dr Tedros Adhanom talked about growing up in Ethiopia, saying he comes from a background of “knowing survival cannot be taken for granted, and refusing to accept that people should die because they are poor.” He spoke about the need for universal access to health care, a better response to health emergencies and the need to tackle gender-based violence, as well as threats to global health like climate change. He wrote in his application "“I envision a world where everyone can lead healthy and productive lives, regardless of who they are or where they live.” We look forward to contributing to what this implies for health equity, globally and in our region.
EQUINET NEWS IS THE ELECTRONIC MAILING LIST OF THE NETWORK FOR EQUITY IN HEALTH IN SOUTHERN AFRICA (EQUINET) http://www.equinetafrica.org/ EQUINET NEWS is a newsletter designed to keep you informed about materials on the Internet on equity and health in southern Africa, focusing primarily on EQUINET's principal themes. The newsletter also includes news about Equinet activities, policy debates or theme work to keep you updated on work taking place. Further information on the materials in these briefings is available from TARSC (email: admin@equinetafrica.org).
New year greetings! The EQUINET newsletter is now in its 168th issue and has been disseminating information on health equity in east and southern Africa for seventeen years. Thanks to all who have contributed. We'd like to hear more from you! We invite readers to submit short think pieces, debate pieces and information for the newsletter relating to the diversity of health equity issues affecting east and southern Africa. Please submit oped pieces of 1000 words or less with author name and institution to admin@equinetafrica.org. We also welcome information on useful resources, published papers, conferences and research grants on health. The newsletter and EQUINET website have searchable databases of publications on health equity in east and southern Africa as a resource for those engaging in various areas of research, policy and activism in health.